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N Waste Tire Su :ay & Inspection Report ,ispection Report Number <br /> Slate of California <br /> 1(New 04104) <br /> Cal fomia In egrat dtWaste Management Board Survey Form - Page 1 0 1127740 <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �� �t `'L I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (blk 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L Inspected By Inspector <br /> �_ul"A M'kv U N I l <br /> Physical Address 0 & <br /> cA Inspection Date � � � � 7 O <br /> �Yd1�WV,J, Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> 0 P 5 0 P <br /> Q L" _Q_�, �,1� MS�NYV 1�� 1 n Operational Status Tire Type Business Role Storage Type <br /> \l <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 41 Active 0 Passenger 41 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> (^7P� Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 11 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A J HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IN In Compliance - No Violations <br /> 0 1 Q 1 Other: § <br /> Comments <br /> RoAne— csSsel c6k cj';� 1)�ko&A4 U)D5 <br /> Inspection Form Include <br /> Comments Inciud <br /> es ep s Signa un: hone Number Inspe r' , t ature phone Number <br /> INSTRUCTIONS ON BACK Correct: correct: Il v} }I p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L ® ■ <br />